Previous Topic

Next Topic

Can non-small cell lung cancer be found early?

Usually symptoms of lung cancer do not appear until the disease is already in an advanced, non-curable stage. Even when symptoms of lung cancer do appear, many people may mistake them for other problems, such as an infection or long-term effects from smoking. This may delay the diagnosis.

Some lung cancers are diagnosed early because they are found by accident as a result of tests for other medical conditions. For example, lung cancer may be found by imaging tests (such as a chest x-ray or chest CT scan), bronchoscopy (viewing the inside of lung airways through a flexible lighted tube), or sputum exam (microscopic examination of cells in coughed up phlegm) done for other reasons in patients with heart disease, pneumonia, or other lung conditions. A small portion of these patients do very well and may be cured of lung cancer.

Screening is the use of tests or exams to detect a disease in people without symptoms of that disease. Doctors have looked for many years for a test to find lung cancer early and help people live longer, but only in recent years has a study shown that a lung cancer screening test can help lower the risk of dying from this disease.

The National Lung Screening Trial

The National Lung Screening Trial (NLST) was a large clinical trial that looked at using a type of CT scan known as low-dose CT (sometimes called low-dose spiral or helical CT) to screen for lung cancer. CT scans of the chest provide more detailed pictures than chest x-rays and are better at finding small abnormalities in the lungs (discussed in more detail in the next section). Low-dose CT (LDCT) of the chest uses lower amounts of radiation than a standard chest CT and does not require the use of intravenous (IV) contrast dye.

The NLST compared LDCT of the chest to chest x-rays in people at high risk of lung cancer to see if these scans could help lower the risk of dying from lung cancer. The study included more than 50,000 people aged 55 to 74 who were current or former smokers and were in fairly good health. To be on the study, they had to have at least a 30 pack-year history of smoking. A pack-year is the number of cigarette packs smoked each day multiplied by the number of years a person has smoked. Someone who smoked a pack of cigarettes per day for 30 years has a 30 pack-year smoking history, as does someone who smoked 2 packs a day for 10 years and then a pack a day for another 10 years. Former smokers could enter the study if they had quit within the past 15 years. The study did not include people if they had a prior history of lung cancer or lung cancer symptoms, if they had part of a lung removed, if they needed to be on oxygen at home to help them breathe, or if they had other serious medical problems.

People in the study got either 3 LDCT scans or 3 chest x-rays, each a year apart, to look for abnormal areas in the lungs that might be cancer. After several years, the study found that people who got LDCT had a 16% lower chance of dying from lung cancer than those who got chest x-rays. They were also 7% less likely to die overall (from any cause) than those who got chest x-rays.

Screening with LDCT was also shown to have some downsides that need to be considered. One drawback of this test is that it also finds a lot of abnormalities that have to be checked out with more tests, but turn out not to be cancer. (About 1 out of 4 people in the NLST had such a finding.) This may lead to additional tests such as other CT scans or more invasive tests such as needle biopsies or even surgery to remove a portion of lung in some people. These tests can sometimes lead to complications (like a collapsed lung) or rarely, death, even in people who do not have cancer (or who have very early stage cancer).

LDCTs also expose people to a small amount of radiation with each test. It is less than the dose from a standard CT, but it is more than the dose from a chest x-ray. Some people who are screened may end up needing further CT scans, which means more radiation exposure. When done in tens of thousands of people, this radiation may cause a few people to develop breast, lung, or thyroid cancers later on.

The NLST was a large study, but it left some questions that still need to be answered. For example, it’s not clear if screening with LDCT scans would have the same effect on people different than those allowed in the study, such as those who smoke less (or not at all), or people younger than age 55 or older than 74. Also, in the NLST, patients got a total of 3 scans over 2 years. It’s not yet clear what the effect would be if people were screened for longer than 2 years.

These factors, and others, need to be taken into account by people and their doctors who are considering whether or not screening with LDCT scans is right for them.

American Cancer Society’s guidelines for lung cancer screening

The American Cancer Society has thoroughly reviewed the subject of lung cancer screening and issued guidelines that are aimed at doctors and other health care providers:

Patients should be asked about their smoking history. Patients who meet ALL of the following criteria may be candidates for lung cancer screening:

55 to 74 years old

In fairly good health (discussed further down)

Have at least a 30 pack-year smoking history (this was discussed above)

Are either still smoking or have quit smoking within the last 15 years

These criteria were based on what was used in the NLST.

Doctors should talk to these patients about the benefits, limitations, and potential harms of lung cancer screening. Screening should only be done at facilities that have the right type of CT scan and that have a great deal of experience in LDCT scans for lung cancer screening. The facility should also have a team of specialists that can provide the appropriate care and follow-up of patients with abnormal results on the scans.

For patients

If you fit all of the criteria for lung cancer screening listed above, you and your doctor (or other health care provider) should talk about starting screening. He or she will talk to you about what you can expect from screening, including possible benefits and harms, as well as the limitations of screening.

The main benefit is a lower chance of dying of lung cancer, which accounts for many deaths in current and former smokers. Still, it is important to be aware that, like with any type of screening, not everyone who gets screened will benefit. Screening with LDCT will not find all lung cancers, and not all of the cancers that are found will be found early. Even if a cancer is found by screening, you may still die from lung cancer. Also, LDCT often finds things that turn out not to be cancer, but have to be checked out with more tests to know what they are. This can mean more CT scans, or even invasive tests such as a lung biopsy, in which a piece of lung tissue is removed with a needle or in surgery. These tests have risks of their own (see above).

At this time, government and private insurance programs are not likely to provide coverage for a LDCT done for lung cancer screening.

Screening should only be done at facilities that have the right type of CT scanner and that have experience in LDCT scans for lung cancer screening. The facility should also have a team of specialists that can provide the appropriate care and follow-up of patients with abnormal results on the scans. You might not have the right kind of facility nearby, so you may need to travel some distance to be screened.

If you and your doctor decide that you should be screened, you should get a LDCT every year until you reach the age of 74, as long as you remain in good health.

If you are a current smoker, you should receive counseling about stopping. You should be told about your risk of lung cancer and referred to a smoking cessation program. Screening is not a good alternative to stopping smoking. For help quitting smoking, see our document Guide to Quitting Smoking or call the American Cancer Society at 1-800-227-2345.

What does “in fairly good health” mean?

Screening is meant to find cancer in people who do not have symptoms of the disease. People who already have symptoms that might be caused by lung cancer may need tests such as CT scans to find the underlying cause, which in some cases may be cancer. But this kind of testing is for diagnosis and is not the same as screening. Some of the possible symptoms of lung cancer that kept people out of the NLST were coughing up blood and weight loss without trying.

To get the most potential benefit from screening, patients need to be in good health. For example, they need to be able to have surgery and other treatments to try to cure lung cancer if it is found. Patients who require home oxygen therapy most likely could not withstand having part of a lung removed, and so are not candidates for screening. Patients with other serious medical problems that would shorten their lives or keep them from having surgery may also not be able to benefit enough from screening for it to be worth the risks, and so should also not be screened.

Metal implants in the chest (like pacemakers) or back (like rods in the spine) can interfere with x-rays and lead to poor quality CT images of the lungs. People with these types of implants were also kept out of the NLST, and so should not be screened with CT scans for lung cancer according to the ACS guidelines.

People who have been treated for lung cancer often have follow-up tests, including CT scans to see if the cancer has come back or spread. This is called surveillance and is not the same as screening. (People with a prior history of lung cancer were not eligible for the NLST.)